Today, nursing is a highly complex and challenging profession that exists within a rapidly changing health care environment. Thus, it is imperative that nurses be proficient in the current knowledge and procedural skills necessary for providing safe and effective care. Numerous authors have emphasized the need for nurses to be able to think critically to use the appropriate knowledge and skilled judgments in delivering patient care (Brooks & Shepherd, 1990; del Bueno, 1992; Ford & ProfettoMcGrath, 1994; Krammer, 1993; Miller & Malcolm, 1990; & Paul & Heaslip, 1995; Tschikato, 1993). They agree that critical thinking and decision-making skills are essential to the future of professional nursing.
Benner, Tanner, and Chesla (1996) have conducted extensive nursing research that has evaluated critical thinking and clinical judgment skills. These authors use the term "clinical judgment" when referring to clinical decision-making. They assert that nurses must possess clinical judgment to evaluate salient information and respond in a concerned and involved manner in patient care situations. Benner et al. (1996) concluded that the clinical judgment needed for this level of response requires both the deliberate, conscious, decision-making characteristics of competent performance and the holistic discrimination and intuitive response typical of proficient and expert performance.
One must question what thinking skills are needed to develop holistic discrimination and the intuitive responses? When do these responses begin developing? Are the terms "clinical judgment," "clinical decision-making," "critical thinking," often used interchangeably in the nursing literature referring to the same set of skills? Is critical thinking needed for clinical judgment or clinical decision-making? Loving (1993) alleged that the concept of critical thinking encompasses problem-solving, decision-making, clinical judgment, and creativity. The importance of possessing these skills is well documented in the literature but the relationship of critical thinking to clinical judgment remains unclear.
How the education process impacts the development of critical thinking and clinical judgment also remains unclear as does the question, "Do students who possess critical-thinking skills have sound clinical judgment skills?" Theoretically, the acquisition of both critical thinking and clinical judgment begins with the education process (Brigham, 1993; Brooks & Shepherd, 1990). During all phases of nursing education, the students initially are taught theory in the classroom followed by psychomotor skill demonstrations that are practiced in simulated situations. The student must then transfer and apply this classroom knowledge to the clinical setting in a variety of patient care situations (Jenks, 1993). This requires transferring theoretical knowledge and psychomotor skill development from the classroom to the clinical setting, and making applications to a variety of health care problems manifested by the patient. This application process as defined here is dependent on the acquisition of critical thinking and clinical judgment, and is supported in the literature (Jenks, 1993; Loving, 1993; & Tschikota, 1993).
Since 1989 the National League for Nursing (NLN), the national accrediting body for nursing programs, has mandated that baccalaureate programs demonstrate the assessment of critical thinking as a student outcome (Grabin, 1991). Thus, to become nationally accredited and maintain accreditation, critical-thinking skill development needs to be evident in students throughout the program and measurable at the time of graduation (Grabin, 1991).
The question arises, is it enough to measure only critical thinking? If a graduate from a baccalaureate nursing program possesses critical-thinking skills, does this mean that he/she has the clinical judgment skills necessary to be a safe practitioner? Is there a relationship between critical thinking and clinical judgment?
This study was conducted to evaluate the relationship of critical thinking to clinical-judgment abilities in baccalaureate nursing students at the completion of their program. In addition to critical thinking, the effect of additional variables on clinical judgment was also evaluated: age, years in college, and cumulative grade point average (GPA) of nursing students while in their nursing program.
Researchers concur that critical thinking and clinical judgment are both necessary to make the rigorous and honest inquiries required to care for a patient or a group of patients (Carpenito, 1995; Kataoka-Yahiro & Saylor, 1994; Miller & Malcolm, 1990; Tanner, 1983;). Early research found no consistent relationship between critical-thinking skills and the development of clinical judgment (Brooks & Shepherd, 1990; Frederickson & Mayer, 1977; Pardue, 1987). Kataoka-Yahiro & Saylor (1994) purported that a lack of refinement in design and instrumentation rather than a lack of relationship between critical thinking and clinical judgment were the reasons for the inconsistent results.
In 1991, Kintgen- Andrews conducted a literature review about the assumption that the strength of critical thinking impacts upon nursing performance, particularly in clinical judgment. Strong support for the impact of nursing education on generic critical thinking was lacking. There was, however, support for the impact of nursing education on clinical judgment. There was "practically no evidence of congruence between the two (p. 154)."
Later research attempted to demonstrate a relationship between the development of clinical judgment as it related to critical thinking (del Bueno, 1992; Gordon, Murphy, Candee, Hiltunen, 1994; Kataoka-Yahior, 1994; Loving, 1993; Tschikota, 1993). Loving supported clinical judgment as a cognitive process, which played a role in the development of critical-thinking abilities. He concluded that further research was needed on methods of measurement and instruction of clinical judgment. Kataoka-Yahiro and Saylor (1994) developed a Critical Thinking Model for Nursing Judgment that defined the concept of critical thinking as the first step toward analysis and use in nursing. Critical thinking was used as the theoretical framework for this model.
A growing body of literature has emerged that discusses the relationship of critical thinking to clinical judgment in various clinical settings (del Bueno, 1992; Miller & Malcolm, 1990; Tanner, 1983; Tschikota, 1993). Researchers, Brooks & Shepherd (1990) identified critical thinking as a necessary component for the development of clinical judgment. Miller and Malcolm (1990) actually defined critical thinking as clinical judgment. These authors believed clinical judgment was the outcome of thinking critically.
Investigators in the field of decisionmaking and critical thinking have assumed that there is a set of intellectual processes that result in good judgment (Tanner, 1993). However, research results regarding critical thinking, clinical judgment, and the inter-relationship between the two variables are inconclusive. There continues to be a need to further explore this relationship as two of the intellectual processes assumed by Tanner. One way to evaluate the effect of educational practices on these processes is through the assessment of student outcomes upon graduation from nursing programs.
Research Design. This study employed a correlational design that explored the relationship between critical thinking, age, years in college, cumulative GPA, and clinical judgment.
Setting I Sample. A convenience sample of 65 nursing students from two baccalaureate-nursing programs in Northern California was used to assess the relationship among the variables. The nursing programs from which the students were recruited were selected because both programs were in four-year public institutions, had comparable admission requirements, and offered similar curricula. Students sampled were in their fifth and final semester of these programs. Only students without licensure were included.
Protection of Human Subjects. Permission from the Human Subjects' Review Boards of both participating universities was obtained. The subjects were informed that participation in this study was entirely voluntary and that the results would be made available to them. Informed consent from the subjects was obtained.
Demographic Survey. A demographic survey designed by the investigator was used to collect demographic data. Questions asked included age, cumulative GPA, and total years in college.
Critical Thinking. Critical thinking was defined as a cross-disciplinary conceptual definition that portrays the critical thinker as "habitually inquisitive, well informed, trustful of reason, open-minded, flexible, fair-minded in evaluation, honest in facing personal biases, prudent in making personal judgments, willing to reconsider, clear about issues, orderly in complex matters, diligent in seeking relevant information, reasonable in the selection of criteria, and persistent in seeking results that are as precise as the subject and the circumstances of inquiry will permit (American Philosophical Association, 1990, p. 3)." The California Critical Thinking Skills Test (CCTST), Form A was used to evaluate the above attributes of a critical thinker. Form A is a standardized 34-item, multiple-choice test that targets the core critical-thinking skills regarded to be essential in college education (CCTST Manual, 1993). These items, identified in the study conducted by the American Philosophical Association (APA) in 1990, range from those requiring an analysis of the meaning of a given sentence to those requiring more complex integration of critical-thinking skills.
Items are stated in English, and no technical vocabulary or critical-thinking jargon is used. The items are set in contexts familiar to college age persons. General background knowledge readily available through normal maturation and elementary and secondary schooling is presumed. No discipline-specific college level knowledge is presumed on the CCTST. Some items address topics of a more neutral nature, while others center on controversial topics. The students are given 45 minutes to complete the test.
Internal consistency reliability estimates (Kuder Richardson-20) computed separately by pretest and post-test for the 34-item instrument ranged from .68 to .70. For an instrument of this kind, a Kuder Richardson-20 between .65 and .75 is desirable.
The CCTST is the first critical-thinking instrument to derive its construct validity from the APA Delphi Report conceptualization. As such, the authors of the test believe it represents a significant advance over previously published critical-thinking instrumentation (Facione, et al. 1994). In 1989/90, a validation study and an independent 1992 research project found the CCTST correlates with college level GPA and with SAT verbal and SAT math scores. Regression analyses on CCTST scores of students who had completed an approved college level course in critical thinking indicates that 71% of the variance in CCTST post-test scores can be predicted by a combination of SAT-verbal, SAT-math, college GPA, and the CCTST pretest (F = 239.83, df 4, 397, ? = .001), (Facione & Facione, 1990).
The CCTST was normed using 50 volunteer nursing programs throughout the United States. Data were collected from 1992 through 1997. The mean score on the CCTST was 16.24 (Facione, 1997). The CCTST reports 6 scores: an overall score of one's critical-thinking skills, and 5 subscales. The first 3 CCTST subscales are "analysis," "inference," and "evaluation," because they draw together the major core skills identified in the theory of critical thinking advanced in the Delphi (1990) report. The more traditional characterization, of "inductive verses deductive" reasoning is captured in the pairing of the fourth and fifth CCTST subscale.
Clinical Judgment. Tanner's (1983) definition of clinical judgment was adopted for this study. She specifically defined it as including: (a) decisions regarding what to observe in the patient situation; (b) inferential decisions, deriving meaning from data observed; and (c) decisions regarding actions that should be taken, which will be of optimal benefit to the patient. The Clinical Decision-Making in Nursing Scale (CDMNS) was used to assess clinical judgment. This scale consisted of 40 items, stated in English, about the decision-making processes related to nursing. The answers to this test were rated on a Likert-type scale, ranging from "always" to "never" to reflect perceptions of one's own behavior while caring for patients. Item ratings were summed to obtain a total score, with a potential score range of 40 to 200. The higher scores indicated higher perceived decision-making. Content validity was established by a panel of nurse experts, and reliability procedures produced a final Cronbach's alpha of 0.83 (Jenkins, 1985). The focus of the tool was to determine the perception of clinical decision-making from the perspective of self-reported behavior of undergraduate students enrolled in a baccalaureate nursing program.
Demographic Dato. A total of 126 packets were distributed and 68 packets were returned, generating a return rate of 63%. Three subjects declined to complete the tests for personal reasons.
The subjects' ages ranged from 22 to 50 years of age. The subjects' cumulative GPA while in the nursing program ranged from 2.8 to 4.00. The number of years in college ranged from 4 to 12 years.
CCTST Tbtal Score. A total score of 34 was possible on the CCTST. Scores for this sample ranged from 8 to 27 with a mean score of 18.2 and a standard deviation of 4.2.
CCTST-Subscale Scores. Subscale 1, analysis, was assessed with 9 questions. Correct answers ranged from 2 to 8 with a mean score of 5.0 and a standard deviation of 1.4. Subscale 2, evaluation, was assessed with 14 questions. Correct answers ranged from 1 to 12 with a mean score of 6.8 and a standard deviation of 2.3. Subscale 3, inference, was assessed with 11 questions. Correct answers for inference ranged from 2 to 10 with a mean score of 6.4 and a standard deviation of 1.7.
For the final two subscales, the above distribution of 34 CCTST items was set aside. Of the 34 items, 30 were then reclassified as either inductive or deductive reasoning. Subscale 4, deductive reasoning, was assessed with 16 questions. Correct answers ranged from 3 to 14 with a mean score of 8.9 and a standard deviation of 2.6. Finally, subscale 5, inductive reasoning, was assessed with 14 questions with correct answers ranging from 1 to 12 with a mean of 7.6 and a standard deviation of 2.1.
Analysis of the CCTST and CDMNS. One-tail significance level, the Pearson Product Moment Correlation, and regression analysis were used to evaluate the total CCTST, and the subscale scores, as predictors of clinical judgment. A 1-tail significance level, the Pearson Product Moment Correlation procedure was used for analyzing the relationship between the total score on the CCTST (critical thinking) and CDMNS (clinical judgment). Results indicated that there was a significantly positive relationship between these two variables (r = .21, ? <.05). Four percent of the variance in the CDMNS was explained by the CCTST (r2 = .04).
Analysis of CCTST Subscale Scores and CDMNS. Results revealed that only inductive reasoning (r = .27, p <.05) and inference (r = .23, p < .05) were significant predictors of clinical judgment. Further analyses revealed inductive reasoning (r = .29, p < .05) was the most significant indicator of clinical judgment. The subscalee analysis, evaluation, and deductive reasoning were not found to have a significant relationship with clinical judgment.
GPA, Years in College, and Age
The correlational studies did not demonstrate a significant relationship between the age of the student (r s .09, p = .30), number of years spent in college (r = .15,p = .11), or the student's GPA while in the nursing program (r = .08, p = .26) on the clinical judgment skills. A significant relationship was found between the total score on the CCTST and the student's GPA while in the nursing program (r = .55, p = .00). In addition, all 5 subscales demonstrated a positive correlational relationship with GPA.
The findings of this current study support the previous research that demonstrates a relationship between critical thinking and clinical-judgment abilities. More specifically, the subscales of inference and inductive reasoning had a positive correlation to clinical judgment. According to the CCTST Manual (1993), inference means to assess the credibility of statements, identify, and secure elements needed to draw reasonable conclusions. Inference also means to form conjectures and hypotheses, and to deduce consequences about a given set of facte. The subskills of querying evidence, conjecturing alternatives, and drawing conclusions are included under inference.
A second conclusion that can be drawn from this study is that graduates of these two nursing programs, possess some critical-thinking and clinical-judgment skills. The question remains, how nursing education impacted the development of these skills, and if these skills represent or go beyond the novice level, as defined by Benner (1984).
Implications for Nursing Education
This study demonstrated that there is a significant relationship between critical thinking and clinical judgment and found that the graduates of the two nursing programs under study possessed some level of these two skills. The question remains "Is there a more effective way to facilitate the development of critical thinking and clinical judgment?" Further research is needed that addresses the complexities of teaching these skills and educators need to evaluate the impact of the educational process and design. Finally, curriculum that further augments the development of these desired skills needs to be developed and implemented.
The increasing complexity of nursing practice demands that nurses have the ability to identify health and illness problems with multiple diagnoses and in multiple settings. Practice must depict the skills and strategies needed to make rigorous and honest inquiry into the unique circumstances of such problems (Facione et al., 1994). Researchers continue to concur that both critical thinking and clinical judgment are necessary to make these rigorous and honest queries (Carpenito, 1995; Kataoka-Yahiro et al., 1994; Miller & Malcolm, 1990; Tanner, 1983). These authors' beliefs support the need for educational research to determine how these skills are acquired.
Recommendations for Future Research
This study needs to be replicated with randomly selected schools and subjects so that results can be generalized to greater populations. In addition, a longitudinal study to track patterns of growth in critical thinking and clinical judgment as student's progress through each semester of the nursing program would assist nursing educators in evaluating curriculum for areas of strength and weaknesses, in developing these skills. Tracking these skills after graduation during the first years of practice would also help evaluate skill development. Finally, further studies are needed to discover effective strategies for teaching critical thinking and clinical judgment for nursing students in both the classroom and clinical setting.
The author would like to thank Dr. Annita Watson for her editorial assistance.
- American Philosophical Association. (1990). Critical thinking: A statement of expert consensus for purposes of educational assessment and instruction. The Delphi Report: Research findings and recommendations prepared for the committee on pre-college philosophy. (ERIC Document Reproduction Service, No. ED 315-423).
- Benner, P., Tanner, C, Chesla, C. (1996). Expertise in nursing practice; caring, clinical judgment, and ethics. New York: Springer Publishing Company.
- Brigham, C. (1993). Critical thinking in nursing students progressing through a nursing curriculum. Munice: Ball State University; 1989. Dissertation.
- Brooks, K, & Shepherd, J. (1990). The relationship between clinical decision-making skills in nursing and general critical thinking abilities of senior nursing students in four types of nursing programs. Journal of Nursing Education, 29(4), 391-399.
- Carpenito, L. (1995). Handbook of nursing diagnosis (6th ed.) (pp. 22-41). Philadelphia: J.B. Lippincott Co.
- CCTST Test Manual. (1993). The Delphi Report. Milbrae, California: California Academic Press.
- del Bueno, D. (1992). Experience, education, and nurses ability to make clinical judgments. Nursing and Health Care, 11(6), 290-293.
- Facione, P. (1990). The California Critical Thinking Skills Test (CCTST): Form A&B and the CCTST Test Manual. Millbrae, CA California Academic Press.
- Facione, P., & Facione, N. (1992). The California Critical Thinking Dispositions Inventory (CCTDI) and the CCTDl Test Manual. Millbrae, CA- California Academic Press.
- Facione, N. (1997). Critical thinking assessment in nursing education programs: An aggregate data analysis. Millbrae, California: The California Academic Press.
- Frederickson, K., & Myer, G. (1977). Problemsolving skills: What effect does education have? American Journal of Nursing, 77, 1167-1169.
- Ford, J., & Profetto-McGrath, J. (1994). A model for critical thinking within the context of curriculum as praxis. Journal of Nursing Education, 33(8), 341-344.
- Gordon, M., Murphy, C, Candee, D., Hiltunen, E. (1994). Clinical judgment: An integrated model. Advances in Nursing Science, 16(4), 55-70.
- Grabin, M. (1991). Assessing educational outcomes. New York: National League for Nursing Publication.
- Jenks, J. (1993). The pattern of personal knowing in nurse clinical decision making. Journal of Professional Nursing 32(9) 399405.
- Jenkins, H. (1985). A research tool for measuring perceptions of clinical decision making. Journal of Professional Nursing 1, 221-230.
- Kataoka-Yahiro, M., & Saylor, C. (1994). A critical thinking model for nursing judgment. Journal of Nursing Education, 33(8), 351356.
- Kintgen-Andrews, J. (1991). Critical thinking integrated processes. Journal of Nursing Education, 30(4), 152-157.
- Krammer, M. (1993). Concept clarification and critical thinking: An integrated process. Journal of Nursing Education, 32(9), 406414.
- Loving, G. (1993). Competence validation and cognitive flexibility: A theoretical model grounded in nursing education. Journal of Nursing Education, 32(9), 415-421.
- Miller, M., & Malcolm, N. (1990). Critical thinking in nursing curriculum. Nursing and Health Care, 11, 67-72.
- Pardue, S. (1987). Decision-making skills and critical ability among associate degree, diploma, baccalaureate, and master's prepared nurses. Journal of Nursing Education, 26, 354-361.
- Paul, R., & Heaelip, P. (1995). Critical thinking and intuitive nursing practice. Journal of Advanced Nursing Practice, 22, 40-70.
- Tanner, C. (1983). Research on clinical judgment. In W. Hölzerner (Ed.), Review of research in nursing education. Thorofare, NJ: Slack Incorporated.
- Tanner, C. (1993). Thinking about critical thinking. Journal of Nursing Education, 31(9), 99-100.
- Tschikota, S. (1993). The clinical decision-making process of student nurses. Journal of Nursing Education, 32(9), 389-397.